The form below is for new clients only. If you're already a client of Country Canine, please click here to request an appointment.

Country Canine New Client Registration Form

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Please fill out the form below. Once your registration has been approved, we will email you a waiver to e-Sign. Thank you!

Owner Information

First Name *Required*

Last Name *Required*

Phone Number *Required*

Email *Required*

Address *Required*

City *Required*

State | Province *Required*

Zip Code | Postal Code *Required*

Family Vet Clinic *Required*

How did you find us?

Emergency Contact (Include Phone Number)/Others Allowed to Pick Up *Required*

Owner Question #1: Are we able to call your place of employment in the case of an emergency?

Pet #1 Information

Pet Name *Required*

Breed (Best Guess) *Required*

Sex *Required*

Color Description

Date of Birth

Important: Rabies Vaccine is required for all pets over 20 weeks of age. Current Distemper and Parvo vaccination and/or titer test results are required.

Rabies Expiration

Distemper/Parvo (or DHPP) Expiration

Microchip Code

Weight

Insurance Info

Feeding Notes

Medication Notes

Temperament Notes (Aggression, anxiety, etc? If extensive, tell us in person).

Additional Notes (Anything else we should know? If extensive, tell us in person.)

Pet Question #1: Does your dog have any problem behaviors (chewing, digging, climbing fences, etc)?

Pet Question #2: Is your dog crate trained?

Pet Question #3: What are your dog's favorite activities and/or toys?

Pet Question #4: Does your dog have any specific fears or dislikes?

Mobile Phone Alert: Some phones have difficulty uploading the files below (the form gets reset after uploading). If this happens on your phone, please submit this form using a computer. You can also submit this form on your phone without uploading anything and then email your pet picture and vaccine verification document to us at info@countrycanine.net. Thanks!

Pet Photo (Not Required. 5MB Max. Image Files Only)
Click to Upload Pet Picture

Proof of Vaccinations (5MB Max. Only Images, No PDFs. Take a Picture of Document with Your Phone and Upload It.)

Click to Upload a Picture of Proof of Vaccinations

Click Here to Add a Second Pet

Click Here to Add a Third Pet

ALERT: If you have more than three pets, submit this form once with your first three pets. After submitting the first time, click the link to come back to the form (shown after you submit the form) and fill out this form again with the information for your other pets. The second time you fill it out, you only need to include your name, phone and email in the OWNER section because the business will already have the other info (address, emergency contact, etc) from the first time you submitted the form.

Pet #3 Information